Question

Which of the following signs or symptoms in a patient who is opioid-naive is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? A. Oxygen saturation of \(95 \%\) B. Difficulty arousing the patient C. Respiratory rate of 12 breaths/min D. Pain intensity rating of 5 on a scale of 0 to 10

Short answer

B. Difficulty arousing the patient is the sign of greatest concern.

Step-by-step solution

Understanding the question

First, you need to understand the clinical implications of being opioid-naive, which means the patient has not previously been exposed to opioids and thus may have increased sensitivity to their effects. The question is asking which sign or symptom is the most concerning for a nurse to observe after administration of an opioid to such a patient.

Analyzing each option

Analyze each provided option to determine its significance in the context of opioid administration. Oxygen saturation of 95% is slightly below normal but is not typically a critical concern. A respiratory rate of 12 breaths/min is on the lower side of normal but not necessarily alarming. A pain intensity rating of 5 indicates moderate pain and is an expected outcome indicating that the opioid is providing pain relief. However, difficulty arousing the patient could indicate a severe level of sedation or opioid overdose, making it the most concerning symptom.

Identifying the most critical sign

The critical sign or symptom that requires immediate intervention is one that poses an immediate threat to patient safety. Among the choices provided, the inability to arouse the patient could be indicative of opioid overdose, which can lead to life-threatening respiratory depression. Therefore, out of the options given, this is the sign of greatest concern.

Key concepts

Opioid Overdose

An opioid overdose represents a potentially life-threatening situation, especially in opioid-naive patients who may be more susceptible to the drugs' potent effects. Key signs of an overdose include extreme drowsiness, pinpoint pupils, confusion, and slowed breathing. In the context of the exercise, difficulty in arousing a patient after opioid administration is particularly worrying because this suggests a significant impairment of the central nervous system.

Immediate action must be taken to ensure patient safety, often starting with the assessment of airways, breathing, and circulation (ABCs), and moving on to the administration of naloxone if an overdose is suspected. Education on recognizing signs of overdose can empower both healthcare providers and patients' families to act swiftly to prevent potentially fatal respiratory depression.

Nursing Assessment Post-Opioid Administration

Following the administration of opioids, nurses should conduct a comprehensive assessment to monitor the patient's response to the medication. This includes evaluating the level of consciousness, pain intensity, vital signs, and any signs of adverse reactions. Essential components of the assessment are the patient's respiratory rate, oxygen saturation, ability to be aroused, and the level of sedation.

When caring for an opioid-naive patient, nurses should be particularly vigilant as these patients might react more strongly to opioids.

Use of Sedation Scales

Utilizing sedation scales can help in assessing the level of alertness and determining if the sedation is therapeutic or excessive.

Ongoing Monitoring

Regular reassessment is key to managing a patient's care effectively and safely, especially during the initial hours after opioid administration when the risk of complications is higher.

Respiratory Depression

Respiratory depression is a serious side effect of opioid use and can be life-threatening, particularly in opioid-naive patients. It is defined by a reduced rate and depth of breathing. In a clinical scenario, a respiratory rate of less than 12 breaths per minute can be a cause for concern, although this alone, as in option C of the exercise, may not signify an immediate risk. However, it necessitates close monitoring as it could be a precursor to more severe respiratory depression.

The nurse's role includes continuous monitoring of respiratory function, recognizing early signs of respiratory compromise, and intervening promptly.

Pulse Oximetry

The use of pulse oximetry can help to quickly identify decreased oxygen saturation levels, which is a late sign of respiratory depression, and supplementary oxygen may be required to maintain adequate oxygenation. Advanced monitoring and interventions can mitigate risks and promote patient safety, ensuring the efficacy of pain management without compromising respiratory function.